- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,850.90 / $3,109.00
| Facility | | $1,277.00 | $1,850.90 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.64 / $1,762.95 / $2,162.23
| Professional | | $1,371.64 | $1,762.95 | $2,162.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.88 / $1,859.40 / $1,859.40
| Professional | | $1,404.88 | $1,859.40 | $1,859.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.16 / $2,401.58 / $3,013.65
| Professional | | $1,746.16 | $2,401.58 | $3,013.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.79 / $1,965.66 / $2,928.41
| Professional | | $1,352.79 | $1,965.66 | $2,928.41 |